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The Feline Centre Langford and working together for the benefit of cats

NEUROLOGICAL EXAMINATION OF
THE CAT MADE SIMPLE: Part One
Jeremy Rose VetMB BA DipECVN MRCVS Teaching Fellow in Neurology.

Performing and interpreting a neurological exam in cats This table constitutes a simplistic summary and due to
can present a particular clinical challenge to any vet. In the limitations as such, it is recommended that more
the first of this two part article, Jeremy Rose, Senior comprehensive texts (such as the BSAVA Manual of
Clinical Training Scholar in Neurology, takes us through a Neurology) be consulted for further information
step-by-step approach to the neurological examination of regarding localisation.
the cat to help diagnose those trickier feline patients.
Neurological problems are not uncommon in cats, but Forebrain:
can present a significant diagnostic challenge. Both Altered mentation and behaviour*, seizures*, narcolepsy/
performing and interpreting the neurological examination cataplexy, movement disorders, head turn*, head pressing,
can be problematic in feline patients because cats are pacing*, circling*, hemineglect, central blindness*
not always cooperative during examination and findings (decreased menace response with normal pupillary light
may not always be consistent or reproducible. reflex (PLR)), normal to reduced postural reactions and
If you suspect your feline patient may have a normal to upper motor neuron (UMN) signs in forelimbs and
neurological problem, start by taking a full history and hind limbs.
performing a full general clinical exam. This is essential Brainstem:
for identification of potentially related problems with Altered mentation*, deficits in cranial nerves (CN) 3-12*,
other organ systems, incidental findings and factors decerebrate postures, respiratory and cardiac
that may need to be taken into account when abnormalities, gait changes* (most commonly in all four
performing and interpreting the neurological exam limbs), UMN signs in forelimbs and hindlimbs.
itself. It is also important to remember that a normal Vestibular-cerebellar system:
neurological exam does not in itself rule out a
neurological problem, for example a cat may suffer from
Cerebellum: Intention tremor, dysmetria*, truncal
ataxia*, decerebellate posture, ataxia in all four limbs*.
seizures due to a neoplastic cause and have no other Menace deficit with normal vision and PLR*,
signs of forebrain disease on exam. In this case, a vestibular signs (see below*), anisocoria.
detailed history is critical in determining the nature of
your patients signs. A video of episodes recorded by Peripheral

vestibular system: Circling*, head tilt*,
ataxia (usually of all 4 limbs)*, nystagmus*
the owner can also be useful in these situations.
(spontaneous or positional, usually horizontal or
Aims of the neurological exam rotary with fast phase away from the side of the lesion),
There are two main aims of the neurological exam: strabismus, facial nerve deficits (due to the course of
CN through the middle ear), Horners.
1. To determine if your patients problem is neurological
2. To localise where the lesion(s) is/are within any of Central

vestibular system: Any of the peripheral
vestibular signs above, although nystagmus can be
eight anatomical regions (the forebrain, the
horizontal, vertical, rotary, or variable, in addition to
brainstem, the vestibular-cerebellar system, abnormal mentation*, deficits in any CNs (but 5-12
spinal cord segments C1-C5, C6-T2, T3-L3, L4-S3 and most common) and decreased postural reactions* (in
the neuromuscular system). Lesions may be particular paw placement and tactile placement), with
described as multifocal if more than one of these normal-increased muscle tone and normal-increased
regions are affected. spinal reflexes.
Major abnormalities that can be associated with each of continued onto next page
these regions are summarised in table 1, however, it is
Table 1. Summary of clinical signs associated with the eight
important to note that other localisations may be major neuroanatomical locations.
possible with some of these signs and that other clinical Abnormalities that are common signs for a particular
signs may be found with lesions at each location. localisation are marked with*.

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 NEUROLOGICAL EXAMINATION
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specific tests to examine your patients reflexes and
responses (details on performing tests will be published
C1-C5: in the second part of the article).
Posture/gait changes (forelimbs and hindlimbs), decreased
It is important to complete your neurological exam as
postural reactions (forelimbs and hindlimbs) with UMN signs
comprehensively as your patient will allow before
in forelimbs and hindlimbs*.There may also be Horners,
spinal pain or loss of sensation/pain and an UMN bladder. attempting to localise your lesion in order to allow
assimilation of knowledge. For example, a facial paresis
C6-T2: (cervicothoracic intumescence):
Posture/gait changes (forelimbs and hindlimbs), decreased
in the absence of other deficits is unlikely to have a
postural reactions (all four limbs). forebrain or brainstem localisation as these localisations
With LMN sign in forelimbs and UMN in hindlimbs*. There would usually have a concurrent change in mentation.
may also be spinal pain, UMN bladder and an absent Part 1 - Observation
cutaneous trunci reflex.
This part of the exam is usually performed in a quiet
T3-L3:
room with the cat left in the opened basket on the floor.
Posture/gait changes in hindlimbs only, postural reactions
Cats should ideally be given time to habituate to the
decreased in hindlimbs. UMN signs in hindlimbs with normal
forelimbs*. Schiff-Sherrington posture may be present (but is environment in which they are assessed. Observing the
rare in cats). cat getting out of the basket is often valuable in
There may also be spinal pain, reduced/absent cutenous assessing gait and posture.
trunci reflex, hypoalgesia in hindlimbs, or an UMN bladder. Observation is a particularly pertinent part of the exam
L4-S3 (lumbosacral intumescence): of cats, as any abnormalities identified can then be
Posture/gait changes in the hindlimbs only. prioritised for further localisation with the hands on
LMN signs in hindlimbs with normal forelimbs*. tests when the exam may be limited by the patients
There may also be tail paresis, anal sphincter dilation, temperament. Evaluation of the symmetry of the cat
hindlimb/perianal/tail hypoalgesia, spinal/lumbosacral pain throughout the observation stage of the exam is helpful,
and a LMN bladder.
as asymmetry (for example of the cats features, posture
Neuromuscular: or gait) can be indicative of an abnormality.
Deficits in any cranial nerves (CNs) (7, 9, 10 most common
1. Assess behaviour
in generalised neuromuscular disorders), flaccid paresis OR
stiff/exercise intolerance (myopathy). Normal-abnormal Abnormal behaviours include hemi-neglect syndrome
postural reactions in all four limbs, decreased (most (a problem with sensory input from the environment on
common) to normal to increased muscle mass and/or muscle one side, which may manifest, for example, as only
tone in all limbs, decreased to absent spinal reflexes in all limbs, eating one side of a bowl of food), persistent pacing,
normal to decreased sensation, muscle hyperaesthesia. seizures or head pressing.
These signs are always indicative of forebrain involvement.
Table 1 (continued from previous). It is important to ask the owner specifically regarding
any evidence for these (and other) abnormal behaviours
Signs Upper Motor Neuron Signs Lower Motor Neuron Signs
at home when taking a history,
Reflexes Normal to increased Decreased remember that signs may be
subtle, for example, with
Muscle mass Normal Normal to decreased
partial seizures and must be
Muscle tone Normal to increased Decreased to absent distinguished from other
neurological and non-
Table 2: Reference to Upper Motor Neuron and Lower Motor Neuron signs. neurological causes such as
metabolic or electrolyte
Once you have determined the location of your lesion, disturbances, learned behaviours or other causes of
it is then possible to deduce a list of sensible differential myoclonus.
diagnoses and then select appropriate diagnostics in 2. Assess the level of consciousness
order to correctly determine the diagnosis, prognosis
and management of each case. Changes in consciousness indicate forebrain or
brainstem involvement, however, as for behavioural
Practical approach changes, extracranial conditions can impact on the
There are two main components to the neurological forebrain resulting in changes to consciousness.
exam in any animal. Firstly, it is essential to observe
Observe for mania (inappropriate exaggerated
your patient thoroughly and then secondly, perform

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 NEUROLOGICAL EXAMINATION
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behavioural response to environmental stimuli), production from the lacrimal gland.
obtundation (marked inattentiveness and reduced
responsiveness to environmental stimuli), stupor
(unconsciousness with a significantly reduced response
to environmental stimuli, but can be roused with pain),
or comatose state (unconsciousness with absence of
response to environmental stimuli, including pain).
3. Observe for cranial nerve abnormalities
Nystagmus (involuntary rhythmical movement of the
eyeballs when the head is still). Nystagmus can be an
incidental finding in some cats (e.g. congenital pendular Figure 1. Horners syndrome affecting the left eye.
nystagmus in Siamese, Birman and Colourpoint breeds),
but is usually associated with an abnormality in the Strabismus (visual axes of both eyes are not parallel to
vestibular-cerebellar system. one another) - a very mild strabismus, without other
Determine the nature of your nystagmus (vertical, neurological signs, may be found as an incidental
horizontal or rotary) and the direction of the fast and finding in some cats and congenital convergent
slow phases. With a peripheral vestibular lesion, strabismus has been reported in Siamese, Birman and
nystagmus is usually horizontal or rotary and the fast Himalayan breeds. However, strabismus may indicate a
phase of the nystagmus is usually away from the site of lesion in the neuromuscular system (including the
the lesion. With a central vestibular lesion, nystagmus extra-ocular musculature, the oculomotor, trochlear or
can be horizontal, rotary or vertical and can be towards abducens nerves and the NMJ), the brainstem, the
or away from the lesion. A nystagmus that varies in forebrain or the vestibular-cerebellar system.
direction is usually central in origin. The direction of the strabismus is important and may
offer clues as to the origin. Lesions to the oculomotor
Anisocoria (different sized pupils under the same light
nerve (or associated nuclei which are located in the
conditions). Observe pupil size in both light and dark
brainstem) may cause a ventrolateral strabismus.
conditions, as well as assessing pupillary light response
Lesions to the trochlear nerve or nuclei may cause a
(see later) to ascertain which eye is affected and if it is a
dorsolateral strabismus and lesions to the abducens
failure of dilation (miosis) or failure of constriction
nerve or nuclei may cause a medial strabismus.
(mydriasis) that is present.
Decreased masticatory muscle mass - may indicate a
Abnormalities in the following structures can result in lesion in the neuromuscular system (including
an anisocoria: temporal, masseter, digastricus or pterygoid muscles,
globe (can cause miosis or mydriasis in the trigeminal nerve or the NMJ) or the brainstem.
affected eye) Inability to close the mouth - inability to close the mouth
oculomotor nerve (causes mydriasis on the in the absence of a non-neurological cause, such as oral
ipsilateral side) sympathetic input to the eye obstruction, retrobulbar lesion or orthopaedic problem,
(causing Horners syndrome i.e. miosis, ptosis and may indicate a lesion in the neuromuscular system
enopthalmos ipsilaterally to the lesion) See fig 1. (including the local muscles, bilateral trigeminal nerve
brainstem, including oculomotor nuclei (causes deficit (uncommon) or NMJ) or the brainstem.
mydriasis on the ipsilateral side to the lesion) 4. Observe gait and posture
forebrain (causes miosis on contralateral side to the Look specifically for the presence of the following:
lesion) Head tilt (See figure 2 - rotation of the head about the
cerebellum (can cause mydriasis contralaterally or axis of the median plane of the skull i.e. one ear or eye is
ipsilaterally to the lesion) lower than the other). A head tilt usually reflects a
Facial droop/paralysis - observe for abnormalities in lip vestibular-cerebellar lesion (and can include the
and ear symmetry and for inability to blink. A facial droop brainstem), but can rarely be seen in forebrain disease
may indicate an abnormality in the neuromuscular system and high cervical lesions (C1-C3). A head tilt is usually
(facial musculature, facial nerve and neuromuscular towards the side of the lesion, except in a paradoxical
junction (NMJ), the brainstem or the forebrain (rare)). vestibular lesion, which occurs secondary to a central
If facial nerve involvement is suspected, a Schirmer tear vestibular-cerebellar disorder.
test should be performed as part of your hands on
exam as a parasympathetic branch controls tear

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 NEUROLOGICAL EXAMINATION
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in cats affected by a C1-C5 myelopathy) and this is often
unnecessary but, it is important to decide which limbs
are affected to help with neurolocalisation. If you are
able to identify your patient as ataxic or paretic, you can
try to determine which type is present.
With general proprioceptive ataxia (loss of awareness
of where the limbs are in space), there is commonly a
delay in the onset of protraction (the swing phase)
of the limb, excessive flexion, adduction or abduction
and the presence of knuckling the paw(s) over onto
their dorsal surface.
Vestibular ataxia (loss of balance) may be observed as
Figure 2. Severe left-sided head tilt in a kitten with a a tendency to lean, drift, fall or roll to a particular side
middle ear polyp.
and is often accompanied by an abnormal nystagmus,
Head turn (nose turning to one side of the body but the strabismus and head tilt. Bilateral vestibular lesions
median plane of the head remaining perpendicular to often result in a low crouched posture with wide head
the ground). A head turn indicates a forebrain lesion excursions from side to side and no head tilt.
and is usually toward the side of the lesion. Cerebellar ataxia (inability to modulate gait generating
Circling - can indicate a forebrain or vestibular- systems) usually results in limb movements that appear
cerebellar disease. Circling is usually towards the side to lack control, are abrupt in onset, show overflexion on
of the lesion (except in central vestibular-cerebellar protraction and have an abnormal site of limb placement
disease, where it can be either towards or away from (i.e hypermetric gait). Cerebellar lesions often result in
the side of the lesion). Smaller circles are often a wide-based stance, truncal sway, intention tremors
associated with vestibular lesions and wider circles and menace deficits in the presence of normal visual
with forebrain disease, but this is variable. tracking and PLRs. Cerebellar ataxia may be accompanied
Specific postures (decerebrate, decerebellate and by vestibular signs due to significant components of the
Schiff-Sherrington). central vestibular system being located in close
proximity to the cerebellum. Several congenital
Decerebrate posture, characterised by extension of cerebellar conditions have been reported in cats,
forelimbs and hindlimbs with opisthotonus and a
including cerebellar abiotrophy, cerebellar degeneration
stuporous or comatosed mental state, is due to a
and cerebellar hypoplasia. Note that purely cerebellar
brainstem lesion and carries a poor prognosis.
lesions have normal mentation and no paresis.
Decerebellate posture, characterised by extension of Lower motor neuron (LMN) paresis is usually observed
forelimbs with possible flexion or extension of the
hips, opisthotonus and a normal mental state, is due as difficulty to support weight, which may cause a
to a rostral cerebellar lesion (usually acute i.e. vascular) short-stride length (and therefore mimic lameness), a
and does not necessarily indicate a poor prognosis. tendency to collapse, trembling and/or neck flexion.
Upper motor neuron (UMN) paresis commonly causes a
Schiff-Sherrington posture, characterised by delay in the onset of protraction and a longer stride
extension of forelimbs and possible opisthotonus
with a variable degree of spasticity.
with a normal mental state, is associated with a
T3-L3 spinal cord lesion and is not a prognostic To see a video of a neurological exam being performed,
indicator. It is usually worsened by lateral please visit: www.felineupdate.co.uk
recumbency and patients have normal The next article, discussing the hands on neurological
proprioception in the forelimbs. examination, will be published in the next edition of the
Ataxia and paresis Ataxia is incoordination caused by Feline Update.
a sensory deficit and may be of three types: general References
proprioceptive, vestibular or cerebellar. Paresis is BSAVA Manual of Canine and Feline Neurology (2013) BSAVA
weakness caused by a motor deficit and may be of two Eds S. Platt & N. Olby. 4th Ed. BSAVA. Gloucestershire.
types: upper motor neuron paresis or lower motor Dewey. C. W. (2008) A Practical Guide to Canine and Feline
neuron paresis. Observe the cat walking (on a non-slip Neurology, 2nd Edition. Wiley & Sons.
surface in an area with sufficient space). It can be difficult De Lahunta (2008) Veterinary Neuroanatomy and Clinical
to distinguish between ataxia and paresis (for example Neurology. 3rd Ed. Saunders.

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